1. Buckinghamshire Healthcare NHS Trust Nursing Quality Framework.
Introduction
Reducing harm and monitoring and improving the quality of nursing care delivered to patients is an essential element of the role of all nurses. Whilst there are systems in place within Buckinghamshire Healthcare Trust, they are not 100% robust and standards are not currently at the level aspired to by the Chief Nurse and her senior team.
In order to address this, the Chief Nurse initiated a review of the quality framework, structure and monitoring; this paper outlines the improved system.
Background
The Trust Nursing Service is currently participating in a number of quality improvement initiatives and data collection/benchmarking/monitoring systems including Safety Express, Safety Thermometer, Essence of Care, Releasing Time to Care (Productive ward) and there is encouragement from the Strategic Health Authority to enlist in ‘Energising for Excellence’ the latest initiative from the NHS Institute for Innovation and Improvement (NHS Institute). This has resulted in the requirement for comprehensive data collection by ward managers, matrons and others across a wide range of indicators. This takes a significant amount of time to collect and present; some is on display at ward level though it may sometimes be of little meaning to patients and members of the public.
‘Harm Free’ Care
The Safety Express programme, a powerful measurement system and support, encourages organisations to stop thinking about individual safety issues in isolation and to think about complications from the patient’s perspective. It has focussed on four key harms – pressure ulcers, VTE, urinary catheters and falls – and its aim is the absence of all four harms and achievement of harm free care.
Harm free care is regarded as ‘a new mindset in patient safety improvement’. BHT’s Chief Nurse contributed to the product design and the Trust Nursing Quality Framework incorporates key elements.

2. Energising for Excellence
Text taken from the Department of Health website
“Energise for Excellence in Care (E4E) is a quality framework for nurses, midwives and health visitors which aims to support the delivery of safe and effective care, creating positive patient and staff experiences that build-in momentum and sustainability.
The framework brings together numerous tools, techniques and policies from both a national and local level into one central portal, which is now available from a dedicated section on the DH website.
E4E provides information at the point of care, supporting nursing staff to improve the quality of care and productivity. Good quality, safe effective care improves the experience of both patients and staff, resulting in shorter hospital stays, less patient complaints and fewer staff absences and errors.
Nurses are the biggest workforce in the NHS and the E4E approach gives them the chance to influence how they and their peers work. It empowers individuals to revolutionise the level of care given, increase productivity, reduce spend and ensure that the skill mix for a shift is appropriate to the type of patients on the ward. Understanding the acuity and dependency of their patients will assist nurses in having the right staffing levels to deliver the right care at the right time and in the right place.
E4E is now strategically positioned as the over-arching approach to the implementation of improvement initiatives such as: High impact actions, Productive care, Safety Express, Essence of care. Many of these initiatives are not new and the emphasis is to pick and mix initiatives and ensure that improvement work is happening in each of the E4E domains: Get staffing right, Deliver care, Measure impact, Patient experience, Staff experience.”
QUALITY PACK TMC dlb v

3. BHT NURSING QUALITY FRAMEWORK
The Trust Nursing Service has developed a local version of E4E, based on the work of the NHS Institute and using the same five elements. It also incorporates the primary drivers and many of the secondary drivers of ‘harm free care’; the remaining secondary drivers form part of other structures and processes of the Trust e.g. Active Risk Management and Medicines reconciliation.
The local nursing quality framework will be known as ‘Delivering Excellence in Nursing Practice’.
Measure impact
Patient experience
Staff experience
Get staffing right
Deliver care
CONSISTENT
HIGH QUALITY
CARE
Safer Nursing Care Tool
AUKUH Roster-pro
Birthrate+
Releasing time to Care
Essence of Care
Exec walkarounds
National staff survey
Safety Thermometer
Audits, Matron Rounds
Patient Experience Tracker
PALS & Complaints
National Survey
Get staffing right
Staffing establishments have been reviewed using AUKUH (Association of United Kingdom University Hospitals)/ Safer Nursing Care tool.
The Obstetric Service recognises the importance of the Birth-rate + workforce planning tools
‘RosterPro’ is in place in most nursing areas and will be rolled out across the Trust
Deliver Care
The Productive Team is well established and encouraging the use of the ‘releasing time to care’ concepts and tools
A planned programme of Essence of Care audits provides measurement of essential aspects of care
Staff Experience
The Trust already has a system of Executive Walk-abouts in place and actively encourages staff to respond to the National Staff Survey.
Local staff satisfaction measures are being developed and simple questions have been incorporated into the measurement framework
Measure Impact
The measures to be used to assess the standards of nursing practice are detailed in the appropriate section below.
Patient Experience
The framework builds on the existing system of Patient Trackers and the patient survey element of the Productive Team work as well as other feedback sources
A Structure to Implement the Framework
It is acknowledged that measures and monitoring alone are not sufficient to support real sustained improvement; knowledge, education, and expert support are also essential. To this end a structure is proposed to support improvement in standards of patient care.

4. External Professional Guides/Mentors Group The Quality Support Crew
STRUCTURE
BHT NURSING QUALITY FRAMEWORK – SUPPORTING STRUCTURE
Ward Based Matrons
The role of the Matron is crucial in achieving and maintaining high standards of nursing practice and quality care. The structure places them at the centre; supported by strong nursing leadership at Trust level, experienced external influence, internal support teams, and developmental resources. In addition, as individuals they will have clear objectives and competence development support.
Nursing Leadership
The Chief Nurse and Director of Patient Care Standards, Associate Directors of Nursing, and nurses in other senior positions including Healthcare Governance, Infection Control and Nutrition are committed to and passionate about the delivery of high quality care. They support the Matrons and ward teams to develop and improve through practical support, mentorship and leading by example.
External Professional Guides/Mentors Group
Comprising of around six key individuals within the nursing profession nationally including representation from the Nursing and Midwifery Council, Royal College of Nursing, Nurse Education, this group will provide mentorship and facilitation to the Chief Nurse and Associate Directors of Nursing, external challenge and a wider view of standards and developments in care.
Through its links with these individuals it is hoped that not only would standards of patient care be improved but that the Trust could also enhance its profile in the national nursing arena through acting as early implementer for new initiatives, increased involvement in pre-registration education and outstanding professional practice.
The Quality Support Crew
Members of the nursing team within the Trust considered to be those with an excellent understanding of what constitutes good patient care, ward management and organisation, and professional behaviour. This team would spend a period of time on each ward initially observing care but then working with the staff to improve care and the patient experience.
The amount of time on each ward would be determined by their findings during the initial observation and the order of their attachments would be agreed by the Chief Nurse based on current standards of patient care delivered.
The crew would provide this professional assessment/ expert tutor role whilst retaining their own roles within the organisation.
© copyright BHT 2012

5. BHT NURSING QUALITY FRAMEWORK - TOOL KIT
TOOLS & RESOURCES
BHT NURSING QUALITY FRAMEWORK - TOOL KIT
In addition to the supporting structure, there is also a set of tools and other resources to assist nursing staff in delivering high quality professional care.
Nursing documents
Documents used by nursing staff have been reviewed and revised by a group involving ward staff, Ward Managers and Matrons.
Assessment
To ensure a good understanding of the patient’s usual level of functional ability and how that has altered as a result of their reason for admission, and to identify risks and care needs.
Starting discharge planning on admission by gaining an understanding of home circumstances, significant others /carers, and support from other agencies.
Care planning and evaluation
Simple care plan documents that enable the care needs identified during admission assessment to be noted, goals agreed and nursing care prescribed in a manner that is not onerous but provides a robust record of care planned and delivered, the impact and subsequent changes to care.
Discharge Processes
A revised discharge checklist to guide staff through the key elements of good, timely discharge planning. Also a trust-wide team of Discharge Co-ordinators who facilitate and co-ordinate more complex discharges whilst guiding, supporting and educating ward staff about discharge process, legislation and interaction with other agencies.
Community In-reach
Experienced members of the Adult Community Health Teams visit wards to review patients with a view to them being cared for in the community, supporting ward staff with risk assessment and discharge planning support.
Royal College of Nursing Principles of Nursing Practice
The Principles of Nursing Practice tell us what all people can expect from nursing practice, whether they are colleagues, patients, or the families or carers of patients.
© copyright BHT 2012

6. TOOLS & RESOURCES

7. TOOLS & RESOURCES
BHT Service Standards
Promises and Service Standards
BHT promises everyone who uses its services:
Clean and safe practice
A caring, helpful and respectful attitude 
Respect for your time
Easy access to comfortable and modern facilities
The best clinical care 
These Promises are consistent ‘The Code’ issued by Nursing and Midwifery Council (UK) that all Registered Nurses and Midwives must comply with.
The promises are underpinned by service standards pledges
All staff are given training in the Promises and Standards at induction and planned updates. Additional sessions for teams can be arranged on request
……I set the standard I am responsible for delivering a great service and am committed to my service standards pledges…..
The standard
Commentary & Feedback
The competency
I say what is happening and why
Compassion & Empathy
I am caring and consider others’ feelings and needs
I treat people with respect and dignity
I act in a timely manner and communicate effectively whenever this is not possible
Communication & Delivery
I am accountable for my actions and behaviours;
I take ownership and do not pass the buck
I keep patients and colleagues in the loop
I listen to others, encourage conversation by using open questions and value other people’s views and opinions
Courtesy & Professionalism
I am polite and approachable, courteous and attentive and welcoming at all times
I keep my eyes open and offer help and support to others
I am professional and positive; I am on stage – an ambassador for the organisation
© copyright BHT 2012

8. BHT NURSING QUALITY FRAMEWORK – MEASUREMENT
Delivery against the agreed indicators will be recorded in a database to generate a ‘dashboard’.
Indicators
Matron’s Ward Round
Matrons will conduct ward rounds not less than weekly in each of their areas to observe elements of professional behaviour and nursing practice. The results will be added to the dashboard. These rounds will provide the opportunity to be visible and accessible to patients and their family/carers, to discuss the achievement against the measures with the nurse in charge of the ward, and to observe other elements that influence the standard of patient care and affect the patient experience.
The elements to be observed and measured by the Matrons is shown on the Matron’s Round template.
Nurse sensitive Indicators
There are agreed ‘nurse sensitive’ indicators agreed for use locally by the Nursing Midwifery and Therapy Professional Board:
Cases of BHT acquired MRSA
Cases of Clostridium Difficile (C.Diff)
Number of avoidable, BHT acquired pressure ulcers
Patient falls
Good Practice Measures
Audit will also contribute to assessment of the standard of nursing practice particularly hand hygiene audits, documentation audits and Essence of Care Benchmarking.
General measures
In addition to clinical practice measures, other measures will be taken including patients average length of stay on the ward, staff mandatory training and appraisal levels in the area and staff satisfaction.
Triangulation
The standard of nursing practice assessed through the measures outlined above will be considered alongside patient/service user feedback and other external reviews and data as available.
Frequency of assessment
The various indicators will be measured at different frequencies over a six-month period; wards will be assessed at the end of each six months to determine if they have achieved an Exemplar level of practice. Most indicators have two thresholds: the minimum expected level of achievement, and the level of achievement expected of a team to be considered as delivering exemplar care. However some only have one, this is where the element is one of the ‘avoidable harms’ noted in the introduction to this document.
The frequency of measurement and the thresholds for achievement are shown in the ‘assessment process’ section below.
© copyright BHT 2012

9. MEASUREMENT
© copyright BHT 2012

10. ASSESSMENT PROCESS
© copyright BHT 2012

11. BHT NURSING QUALITY FRAMEWORK – USING THE OUTCOMES
The database containing results and achievements will be held on the intranet to ensure that the information is accessible to the Ward Manager, Matron, Associate Director of Nursing and the Chief Nurse.
The Chief Nurse will report the results and the situation of wards and divisions to the Board on a regular basis via the Healthcare Governance Committee.
Trends and significant negative measurements will form part of the regular 1:1’s between individuals and their line manager so that
actions can be agreed to ensure achievement of minimum standards
good practice can be recognised
actions to achieve further improvement and Exemplar level of practice can be identified and implemented
The implementation of the Quality Framework will have a positive impact on standards of nursing practice .
The data acquired, trends and achievements can be used to provide assurance to BHT Trust Board, local and other service users, commissioners, and other external regulators and NHS bodies.
© copyright BHT 2012

12. LARGER DIAGRAMS

13. BHT NURSING QUALITY FRAMEWORK
LARGER DIAGRAMS
Measure impact
Patient experience
Staff experience
Get staffing right
Deliver care
HIGH QUALITY
CONSISTENT
CARE
Safer Nursing Care Tool
AUKUH Roster-pro
Birthrate+
Releasing time to Care
Essence of Care
National staff survey
Exec walkarounds
Safety Thermometer
Audits, Matron Rounds
National Survey
PALS & Complaints
Patient Experience Tracker
BHT NURSING QUALITY FRAMEWORK
© copyright BHT 2012

14. BHT NURSING QUALITY FRAMEWORK – SUPPORTING STRUCTURE
LARGER DIAGRAMS
BHT NURSING QUALITY FRAMEWORK – SUPPORTING STRUCTURE
© copyright BHT 2012

15. Patient promises … where your needs always come first
LARGER DIAGRAMS
Patient promises … where your needs always come first
Clean and safe practice, clinics and hospitals so you never need to worry unduly A caring, helpful and respectful attitude from approachable teams, who listen to you, involve you in decisions about your care and ensure you’re clear about what to expect Respect for your time with care closer to home, offering choice and flexibility with a minimum of delays and cancellations Easy access to comfortable and modern facilities, offering privacy and dignity, personal space and good healthy food The best clinical care from teams of skilled healthcare professional, who help you improve and maintain your health

16. LARGER DIAGRAMS
……I set the standard I am responsible for delivering a great service and am committed to my service standards pledges…..
The standard
Commentary & Feedback
The competency
I say what is happening and why
Compassion & Empathy
I am caring and consider others’ feelings and needs
I treat people with respect and dignity
I act in a timely manner and communicate effectively whenever this is not possible
Communication & Delivery
I am accountable for my actions and behaviours; I take ownership and do not pass the buck
I keep patients and colleagues in the loop
I listen to others, encourage conversation by using open questions and value other people’s views and opinions
Courtesy & Professionalism
I am polite and approachable, courteous and attentive and welcoming at all times
I keep my eyes open and offer help and support to others
I am professional and positive; I am on stage – an ambassador for the organisation